Across industries, sophisticated organizations are now committing both time and money to their social media marketingcampaigns. But the healthcare industry (including hospitals, B2B medical manufacturers, and health clubs) has hesitated to embrace social media.

A survey of 1,060 U.S. adults by the PwC Health Research Institute found that one-third of respondents considered social media platforms appropriate for the discussion of healthcare. The Journal of Internet Medical Research found that 60% of adults surveyed used the Internet to access medical information. This is a major opportunity – it’s time to get ahead of the curve.

Here's how healthcare institutions can engage on social in a relevant, useful, industry-appropriate way.

Use Images

In a study by Infinigraph, we measured the effectiveness of different posts made by healthcare companies, including hospitals, clinics, and health care foundations. We found that healthcare audiences engaged most with posts containing images.

Keep it Human, Keep it Useful

Some of the most engaged-with Facebook posts contain images, and all link to valuable content. These short posts link to larger articles which tell human interest stories, tapping into audience emotions, or provide useful health information.

A Few Best Practices for Healthcare Marketers

Make your data available. Allow your ratings and reviews, as well as error rates within your database (if applicable) to be made public.

Educate your employees on social media policies. Make the risk of violating the Health Insurance Portability and Accountability Act (HIPAA) clear, and prohibit posting inappropriate information about doctors or patients.

Avoid using social media channels to communicate with patients on sensitive issues. Advise them on a secure, personalized server.

Enlist at least one author, editor, or reviewer on every piece of content that you publish. Include references or links to the source of your content, and date it whenever possible.

Include an “About Us” or “History” section on your website. Present information about qualified staff, services, and facility as well as your purpose, goal, or mission.

Ask for audience feedback through surveys and questionnaires. Make your contact information easy to find, and encourage your audience to get in touch via email, Facebook, and Twitter. When they do reach out, respond promptly and thoughtfully.

Facebook has been demonized tremendously throughout media, with claims that it causes depression, impairs social skills, creates isolation, feeds addictive behaviors, lowers self-esteem, and last but not least, one report claims it can cause eating disorders. The list goes on and on, further supporting the variety of accusations and reports that say Facebook does far more harm than good. People living with diabetes, Facebook is anything but evil, as those living with the two most common forms of the disease will argue that Facebook has become an immense source of support and much-needed connection in their daily lives.

But more, first, on the evils of Facebook: studies have actually documented that seeing posts about the lives of your friends can actually cause a person to feel worse about their own lives. Those most prone to this type of depression are teens, reports the American Academy of Pediatrics: “Researchers have proposed a new phenomenon called ‘Facebook depression’ that develops when preteens and teens spend a great deal of time on social media sites, such as Facebook, and then begin to exhibit classic symptoms of depression.”

While it can’t be denied that having friendships which revolve primarily through the internet could absolutely be detrimental to a person’s social skills for real-life interactions, and the reality that people are far more likely to be criticized and harassed for what they post and say on Facebook when abusers can hide behind a computer screen, Facebook is not all evil.

For people with diabetes, Facebook can be the source of immense comfort, support, kindness, generosity, and empowerment.

Due to the privacy laws of HIPAA, people with diabetes cannot rely on healthcare professionals to inform them of others in their community living with the disease. In the diabetes online community, Facebook has become a source of connection for thousands of people across the globe. Thousands. Some of these connections start through adults or teens living with type 1 or type 2 diabetes, others start through the parents of children with type 1 diabetes connecting with other parents. In general, however, the groups appear to have mixed themselves together, with a larger group of thousands that consists of type 1s, type 2s, teenagers and adults, and parents of children with type 1 diabetes.

Literally, thousands of people with diabetes are connected to each other personally, have met in real life thanks to their relationship on Facebook, and work together to increase the amount of support and advocacy available to those living with diabetes across the globe with events such as#DSMA Twitter Chat (which stands for Diabetes Social Media Advocacy) every Wednesday night at 9 p.m. EST, or DiabetesAdvocates–both of which were born largely due to relationships that evolved through Facebook.

Why is this online social community such a profoundly positive resource for a disease like diabetes? While each type of diabetes has its differences, the varieties of the disease have enough similarities and challenges to bring them together, but the community doesn’t exist just in specified diabetes “groups” or “pages,” they exist through straightforward friendships on Facebook.

Understanding the basics of diabetes is also important:

Type 1 diabetes, for instance, is an autoimmune disease in which the immune system will, at any age between birth and as high as age 50, attack the cells of the pancreas responsible for producing insulin. Insulin is a hormone essential to life in all mammals, as it is the only way glucose from the food we eat can be taken into the cells throughout the body that need that glucose for energy. Without insulin, any human being would eventually die.

Type 2 diabetes, albeit distorted greatly throughout greater mainstream media as pertaining primarily to obesity and eating “too much sugar,” is characterized most commonly in science by a dysfunction in the body’s ability to either produce or utilize insulin; however, it can also be the result of the liver’s overproduction of glycogen, too. In other words, while there is absolutely a correlation with excess body fat and insulin resistance which can lead to higher blood sugars and diabetes, the cause of type 2 diabetes is not simply about sugar and obesity. (If it were that simple, everyone who is overweight or obese would have diabetes and this is not the case.) Some forms of type 2 diabetes can be managed through changes in diet and exercise, while others require oral medications or insulin injections.

Today, there is no cure for either type of diabetes–and no, losing weight will not “cure” diabetes, it simply causes the symptoms of that person’s diabetes to subside, therefore making weight-loss one form of successful treatment for diabetes for some, not all.

One of the largest benefits of Facebook for those with diabetes are the lifestyle lessons and simple support that is shared around actual management of the disease. Gene Bertram, living with diabetes explains, “It’s put me in communication with other diabetics to find out how they are controlling their disease and improving their health.”

Richard Vaughn, who was diagnosed with diabetes in 1945 and continues to thrive today, says, “I did not know about diabetes online until 2006, so that was 61 years before my online experience. After consulting with other type 1 diabetics in the diabetes website support groups, I realized that I had much more to learn. At least 75% of my current knowledge about type 1 diabetes has been learned in the diabetes online community.”

As for the accusations that Facebook actually induces depression, those in the diabetes community have a different perspective:

Lauren Walsh, living with diabetes, explains, “I was diagnosed just over 2 years ago, I was 43 years with 3 kids and a granddaughter. This came out of nowhere, totally unexpected. I have truly found a wonderful community of others with diabetes that I can actually connect with and have even learned from! I love the diabetes online community!”

Michael Kenney, living with diabetes, explains that through Facebook he has been, “encouraged by others and been able to help others get answers to the same questions I had early on in my diagnosis.”

Donna Shuford, married to a man living with diabetes, explains, “It has made me realize I’m not alone. It has allowed me to reach out to other parents with diabetes with multiple children. I would be more depressed about my life without Facebook.”

According to clinical psychologist Dr. Jen Nash of PositiveDiabetes who specializes in treating people with diabetes, depression has proven to be two to three times more prevalent in people with diabetes. If having access to a free, simple resource like Facebook can alleviate some or a great deal of that depression, that’s a very good thing.

Sue Lebarron, living with diabetes, adds, “It helps me keep in touch with people that truly understand the frustrations of diabetes because they have those frustrations, too!.”

Shana Hammer, a mom of children with diabetes, says, “I was able to connect and contact other moms of multiple kids with type 1 diabetes–there are none in my area.”

Todd Williamson, living with diabetes, explains, “Through Facebook, I’ve been able to connect with other people with type 1 diabetes, which is a good thing. As many people as there are with diabetes, I’ve literally yet to meet another person with type 1 in my city. Nobody.”

Jess Buchanan, living with diabetes, adds, “It gives me a place to vent about diabetes and this is dually beneficial: First, friends who also have diabetes comment with things that make me feel better. Secondly, my friends without diabetes often follow up with questions. So basically it’s a chance to both empathize and educate. A win-win!”

In the end, though, both type 1 and type 2 forms of diabetes are constantly ostracized, mocked, and lectured by the general community. Accused of eating too much, being too lazy, being too fat, having given it to themselves or to their children for “eating too much sugar.” And of course, the constant lectures and inaccurate statements about diabetes in the media only adds to the lectures and scolding people with diabetes receive from the world around them.

While people with diabetes find themselves constantly being told by strangers and overly policing friends and family that they need to “eat less sugar, lose weight, and take better care of themselves,” through Facebook these people with diabetes can surround themselves with a community who understands the lesser known aspects of life that make this disease so challenging.

Common phrases and questions those in the Facebook community of diabetes hear include: “Why did you feed your child so much candy? You gave them diabetes!” or “My grandmother had diabetes…she lost both legs, and then she died” or “You have diabetes? You don’t look that fat!” or “Why don’t you just cure it by exercising more?” or Oh, you have diabetes? That sucks!” or “Well, it’s your fault for eating too much candy.”

None of the above statements are actually scientifically accurate observations about life with diabetes or how to treat it. Instead, they are merely misconceptions about diabetes perpetuated by mainstream media.

In reality, there is no one-size-fits all treatment for diabetes. Everyone’s insulin needs and oral medication needs vary and can change easily throughout their entire lives. The constant order to “exercise more often” comes with the overwhelming challenge of actually balancing one’s blood sugar levels during exercise, because exercise can easily cause dangerous drops in blood sugar if not carefully monitored, making exercise one of the hardest things to do more of safely.

Through Facebook, the people in this community have found allies in the daily challenge of balancing their blood sugars around insulin injections, exercise, nutrition, and the daily stressors of life. In life with diabetes, even an adrenaline-rushing ride on a roller coaster or white-water rafting can cause a significant spike in blood sugar.

Even Charlie Kimball, diagnosed with type 1 diabetes in 2007 and recently won the IZOD IndyCar series in Ohio in early August, said about the growing diabetes community online, “I was blown away by the amount of support and outreach. I know there are many people out there with diabetes, and I have met so many, but it still caught me by surprise how impressive and how significant the response was. It meant so much to me to hear from them.”

Kimball continues, “The coolest thing about the diabetes community is that you are now part of this tight-knit community that inspires, shares, and helps one another. If you can help someone with their diabetes, then you help them with their whole life.”

The best part about this online community? Facebook doesn’t require appointments or any 8 to 5 limitations–it’s always there. Thanks to Facebook, says Jennifer Davis, who lives with diabetes, “I know that I am not alone in my struggles with diabetes. I can go online at any time of day and get support.”

Lisa Stoler may have encompassed every benefit of Facebook for people with diabetes in her story, explaining that, “Before I found the diabetes online community in Facebook, I had been completely alone in my diabetes. I never knew anyone else that was like me and felt misunderstood all the time. Now I know there is always someone just a tap away that know what I’m going through.”

Stoler adds, “In the middle of the darkest nights when I’m dragging myself to the kitchen with a low blood sugar, using all my strength to get food, sit in a chair, and stay alive while waiting for my blood sugar to come up, I know I am not alone because of the community on Facebook. There are always at least 10 type 1 diabetes right at my fingertips. And after 42 years as a type 1 diabetic, I thought I know everything but realized I didn’t–I have learned so much from my online friends in the diabetes community, enabling me to take better care of myself and live a healthier, fuller life.”

While emotional “support” gained through chatting back and forth on Facebook may not seem like a vital ingredient to one’s health for most people, for those living with diabetes who know that every day comes with a variety of challenges impacting every aspect of life from breakfast to work to school to relationships to Christmas parties, it is beyond valuable. For this community, Facebook serves as an endless source of support, education, and empowerment in their lives that are impacted 24/7 by life with diabetes.

Facebook has encompassed many things in its nine-year run. From a subtler version of a dating site to a gaming platform and a messaging hub. We’ve seen Facebook and its billion-plus users play a part in influencing politics, the form advertising takes, and how retail happens. Now we’re starting to see Facebook begin to impact science and public health, and it could be Facebook’s biggest industry-changing opportunity yet.

The logic is a simple one: Everyone on Facebook, all 1 billion-plus people, will have an illness at some point in their lives. And, as Facebook’s social creatures are in the habit of doing, that mass of people will share their experience battling disease, ask questions of their friends, and field advice from outsiders. Through the bullhorn of Facebook, healthcare professionals can deliver information 24-7 about flu vaccines, the path of epidemics, and essential preventive care. The social network can influence how and when people respond to disease, and how we manage death and dying. “Facebook has this massive and powerful platform [that] can be deployed for health care,” says Dr. Eric Topol, director of the Scripps Translational Science Institute.

In his book about digital health care, Topol writes about the story of a mother who posted pictures of her sick child on Facebook. People in her network started commenting on those photos. Three, including a cousin who was a pediatric cardiologist, called to tell her her son might have Kawasaki’s disease, a rare genetic disorder. She called her doctor and told her she was on her way to the hospital because she had a “sense” her kid was really sick.

“What [else] was I going to say? Three of my Facebook friends think my kid has an extremely rare childhood auto-immune disorder which I just read about on Wikipedia, and since they all contacted me after I posted a photo of him on my wall, I’m going? It seemed … wrong!” Deborah Kogan wrote on Slate. Once she got to the hospital, she writes, she told the doctor about her Facebook-prompted visit. She claims the doc said, “You know what? I was just thinking it could be Kawasaki disease. Makes total sense. Bravo, Facebook.”

This is only one story, but it does highlight the potential power of the Facebook network effect.

Last May, for example, Facebook made registering as an organ donor an official “Life Event.” Theoretically, users always had the option to tell their friends they wanted someone else to benefit from their body after they died. But publicizing that information was likely not high on the list of things people thought of sharing when they logged in. Facebook changed that, at least for a time.

About 6,000 people in 22 states registered as organ donors on the first day after the announcement was made, up from an average of about 360. That spike in registrations may have trailed off because users were not continuously reminded of this option, but the social experiment showed the influence Facebook could have on public health, say experts studying the collision between digital tools and health care.

Facebookers can already add overcoming an illness, losing weight, breaking bones or having their braces removed to their Life Events under the category “health and wellness,” but those updates provide very limited information about health.

Physicians, Topol says, don’t even know what normal, minute-by-minute blood pressure should be. That’s a problem because millions of Americans suffer from high blood pressure. But what if researchers could reach even a fraction of Facebook users who have this condition and prompt them to participate in a research study that tracked their blood pressure, along with other metrics like activity levels and heart rate through digital sensors? What if at some point in the future, there was even an option to share genetic information on your Facebook profile? With its growing cross-section of users, Facebook “could really get us an enriched data set,” Topol says.

That assumes, of course, that the data will be reliable, that Facebook will work with scientists to do research as it currently does, and that people will be willing to share personal health information given concerns about how Facebook or third parties might use their data. If you post that you have insomnia for example, would sleep medication ads suddenly pop up?

Those kinds of questions, and the cautious nature of the health care industry, have tended to keep the flow of health related data on Facebook fairly unsophisticated. Until now, Facebook has mostly served as a platform to disseminate information on the cheap. “More hospitals are on Facebook than any other social platform,” said Lee Aase, director of the Mayo Clinic Center for Social Media. Organizations use it, Aase says, to raise awareness about local blood drives, mental health services, free vaccinations, STD/HIV testing, or prenatal care.

Physicians, who you might think would love to use Facebook as a natural hub to communicate with their patients, have mostly shied away from it and other social media platforms to interact with patients because of concerns over professionalism and legal liabilities due to patient confidentiality laws.

But there are signs that the healthcare crowd is warming up to Facebook, in particular research scientists are increasingly using Facebook as a tool. Currently, there have been roughly 400 academic papers published in the last four years that mention the social network, according to a search for the word ‘Facebook’ on PubMed, a public database of biomedical and life sciences research. That’s not many, but the number of such articles published each year seems to be growing. Some of these studies are trying to tease out whether Facebook could be a valid teaching tool for dentistry, histology and continuing education, which suggests the field might be getting more comfortable with the idea of using social media more widely.

In September, researchers from the University of California, San Diego, in collaboration with Facebook’s Data Science group, published a study of 61 million Facebook users in the journal Naturethat suggested political messaging on Facebook influenced real-word voting of millions in the 2010 congressional elections. When users were told that their friends had voted, they were slightly more likely to vote themselves. Although the effect was small, “they translate into a significant numbers of votes” if extrapolated into a real-world scenario, according to an editorial published with the report. Imagine if the same could be shown for public health campaigns on Facebook? Scripps’ Topol asks.

A recent study highlights the opportunities which online social networks may provide to analyze the impact of social behavior on health outcomes such as the prevalence of obesity.

For several years researchers have been trying to find the causes of obesity, aside from any genetic predisposition. Our social environment is regarded as one of the decisive factors overall. For example, families living in deprived circumstances are often prone to obesity because, it is argued, cheaper food is often more fatty and sugary –although this supposed causal link still remains controversial. Such studies have their limitations, since there is relatively little reliable information available on people’s physical activities and dietary habits. However, there is today one source, though rather unconventional as regards public health studies, which can provide a wealth of data: Facebook. Recently four researchers from Harvard Medical School, working together with the Center for Disease Control and Prevention Behavioral Risk Factor Surveillance– an ongoing telephone health survey system – and NYC EpiQuery systems, a web-based system designed to provide health data from a variety of sources, set out to examine the relationship between Facebook users’ ‘likes’ and their weight*.

Studying populations through the lens of social networks

This is one of the first attempts to study the health of a population by extracting data from online social networks. Recently, another online study, carried out via social networks among 61 million people, which looked at the influence of messages on voting patterns, has already demonstrated the potential of social networks for this type of study. Such networks provide a new source of usable data and Facebook is one of the most useful tools since users tend to volunteer information on their surroundings, origins, background and personal interests. Moreover, the sheer size of the network in terms of its user base is an argument in itself for using this data source. In the United States, half the population is active on Facebook, as is one person in eight worldwide. The study on obesity analyzed Facebook users’ ‘likes’, broadly categorizing them under "health and fitness" and "outdoor physical activities" as an indication of being physically active, and "television" as a marker for a sedentary lifestyle. The study reveals that in the US as a whole there is one clear link between Facebook users’ ‘likes’ and obesity: in any given area of the country, a greater proportion of people with activity-related Facebook interests and a smaller proportion who like television appears to be correlated with a lower prevalence of obesity.

Gathering data on public health

The major increase in obesity on a global scale suggests that a person’s social environment says a lot about his/her health. Many studies have already examined the relationship between people being overweight and their immediate environment. For example, in places where there is less opportunity for people to walk, we find higher rates of obesity. Beyond the physical environment, this study now shows that people’s social environment may also be linked to obesity. There are many variables – among them common interests, whether active or sedentary – which make it easier to pinpoint populations at risk. Up to now, obtaining data relating to the social environment of these populations has been costly and slow, and the process difficult to carry out across a large population. The availability of online social network data for this type of study therefore seems to have come at the right moment. Further research is now needed to better understand how the online social environment actually relates to health outcomes and how it can be used to identify when action is needed or target specific interventions.

*‘Assessing the Online Social Environment for Surveillance of Obesity Prevalence’ by Rumi Chunara, Lindsay Bouton, John W. Ayers and John S. Brownstein

Healthcare practitioners can share medical images using a number of mechanisms and methods. Some of these applications have been in use for at least 20 years, some are still being developed, and some might not make sense today but could very well change how we share images in the near future.

Some applications might seem far-fetched, particularly regarding image exchange using social media. However, one should remember that the most common critique when Twitter was still in its infancy was that "it did not have a purpose" -- until the Arab Spring occurred, in which social media played a major role.

Therefore, I would not reject image sharing via social media as being far-fetched, but rather take it as a valid option. Before we consider image sharing on Facebook, I want to describe image sharing use-case scenarios and then look at how we can accomplish this with different architectures. I'll also list the communication options and discuss the maturity of these solutions.

Use cases

While radiology studies are the most commonly exchanged images for review and evaluation, practitioners in pathology, ophthalmology, dermatology, and many other specialties also require image sharing. The most popular use cases are described below.

Emergency medicine scenario: Often during off-hours, a study has to be reviewed and reported, causing a preliminary report to be generated and sent back to the requester within a very limited time frame, e.g., 15 to 30 minutes. A more detailed report is often created when a radiologist or other specialty practitioner is available, such as during regular working hours.

Primary radiology coverage: This is when a radiologist is not present onsite, as is often the case in rural areas, or when a radiologist covers clinics in the suburbs or provides coverage for disaster or war zones. In this case, exchanging images with the onsite clinicians is essential. Instead of the "preliminary" read as used in the emergency scenario, the practitioner creates a final report.

Second opinion: When a specialist is looking for an opinion from a peer who might have more experience with a certain imaging modality or particular disease pattern, an image exchange is needed. This is common when new modalities or acquisition techniques are implemented, such as PET/CT or PET/MR. A sick patient may also present after returning to the U.S. following travel to a tropical country, and physicians might need a second opinion for a disease, such as malaria, that's uncommon in their particular region. Social media might also play a role in this scenario.

Comparison or referral: This occurs when the primary reason for the image exchange is not to make a diagnosis from the original study, as that already has taken place, but to have the previous studies available. For example, a patient is treated in another location, and previous exams have to be viewed for either comparison to a new study or, what is more often the case, to assess the patient's condition without having to repeat that procedure again. This scenario "reuses" the studies and reports as input to diagnosis and further treatment.

Implementation

Each image-sharing application does not necessarily have a single implementation. A certain use case can be implemented using different methods, although some of the architectures are more suitable to specific use cases than others. Let's look at the mechanisms to exchange the studies.

Point-to-point modality to viewer: A technologist can push certain studies directly from a modality, such as a CT in an emergency room, to a doctor's home for review at his or her DICOM viewer. There is a direct connection from the CT to the physician.

PACS to viewer: A PACS could be set up to route all stat studies arriving from a modality directly to a physician's workstation. This is similar to the point-to-point modality to viewer push approach, but it offers the advantage of having a copy available at the PACS to be used as an intermediary. If there are multiple modalities that have to share images, the sending can be centralized from a single source, i.e., the PACS router. If a PACS does not support sophisticated routing using rules determined by information in the image header in order to determine what information goes where, one could use an add-on image router that can be provided by several manufacturers.

PACS worklist: Images are sent to the PACS, and the radiologist has access to the PACS worklist using the PACS workstation. The workflow management features of the PACS can be used to indicate which studies are stat, which ones are being read, etc. This works well if a radiologist only reads from one hospital or multiple institutions that all have the same PACS. The same workflow is used whether the radiologist reads the images locally or accesses the PACS from a remote location.

Aggregate PACS: If the radiologists have to read from multiple, different PACS, it makes sense for them to use their own mini-PACS servers and worklist management. This is typically how nighthawk or emergency medicine works, as these radiologists support many different hospitals, each with their own PACS from different vendors. The images are therefore routed from either the modality or the PACS to a teleradiology PACS server, which aggregates the multiple worklists into a new "combined" worklist. The radiologist then retrieves the image from the teleradiology server and does the reporting.

PACS Web server: Several PACS provide a Web server, or one can purchase a Web server from a different vendor. The Web server can be embedded in the PACS core software or implemented as a separate hardware box that will have a copy of the images from the PACS. Images are typically retrieved over the Web and if one uses a true zero-footprint viewer, there is no trace left on the viewer after the user logs off, which satisfies privacy and security regulations. The worklist capabilities are often not present or are less sophisticated than when using the aggregate PACS worklist. However, the advantage of a separate versus an integrated Web server is that images are available even if the PACS might be down, and therefore this access type can also serve as a backup. One could also use a mini-Web server which gets the information directly from the acquisition modality, but this only makes sense for a small clinic with only one or two modalities and no PACS to speak of.

EMR: Instead of using a PACS, one can also use an electronic medical record (EMR) to view the images. The advantage is that there is much more contextual information available, including lab results, previous reports, patient history, etc. Image enabling of an EMR differs from vendor to vendor. One can use a PACS plug-in, which basically launches a viewer inside the EMR window after exchanging the appropriate context information such as an accession number, or do a query and retrieval from the EMR viewer to the PACS database or from an enterprise image manager and archive solution such as a vendor-neutral archive (VNA).

Image sharing using the cloud: Images can be exchanged using an external image-sharing service, which functions as a broker and forwards the images to the recipient. There are two versions: either the cloud service provider uses only a store-and-forward mechanism, or the cloud functions as a repository and keeps the images for a certain time period. Institutions need to subscribe to the cloud service provider for a fee. This solution makes sense for institutions that regularly exchange information but not often enough to warrant a dedicated link to each other. A good example would be an academic or specialty hospital with relationships with several other institutions in a geographic area that refer patients on a regular basis and want to exchange images. Note that the institution is tied into one particular cloud provider that exchanges the information, which is typically in a proprietary method.

Image sharing using a health information exchange (HIE): This implementation method employs the same architecture used by the commercial cloud provider, but it follows open standards. The HIE can be private, such as within a provider network with several hospitals and/or clinics, or it can be public, such as those being established as part of the incentives by the U.S. federal government to improve healthcare.

Image sharing using a personal health record (PHR): The main applications of the many PHRs that are being rolled out include scheduling appointments, reordering prescriptions, accessing physician notes, and maintaining a communication channel between the patient and provider. The ultimate PHR would also allow the maintenance of certain healthcare information, and it could be used for patients to upload their images to have them available whenever needed. A patient would simply authorize the provider access to the information, which can then be exchanged in a standard manner.

CD exchange: For comparison or referral purposes, images are often hand carried by the patient, a method that comes with its own logistics and interoperability challenges. A chronically sick patient might have literally dozens of CDs that need to be exchanged at each appointment with a different specialist. Also, there are still institutions that do not create these CDs in a standards-compliant manner, making them impossible to read and/or import to a workstation for comparison. The American Medical Association has complained about the wide variety of embedded image viewers, but, unfortunately, the resulting Integrating the Healthcare Enterprise (IHE) profile definition to standardize viewer features and icons does not seem to have gotten much traction. CDs are still the most common method of exchanging images for referral, which one hopes will be replaced in the not-too-distant future with other image-sharing options described here.

Image sharing using social media: It is not uncommon for patients to post their images publicly on the Internet, sometimes just to share them, but also to ask for advice, in particular if it concerns a rare disease or something that is hard to diagnose. It is similar to radiology portals posting their "case of the day" or of the week, but with the difference that the diagnosis is not (yet) known. There are also physicians who use their own Facebook account or other social network to ask for advice. This is still an exception, and it seems to contradict the increasing emphasis on patient privacy. However, I would argue that this might be a valid option if a patient has no interest in keeping his or her information private, but rather would like to get as much exposure as possible for these images to get as many opinions as possible.

Connectivity

Network connectivity between the sending and receiving sides can be implemented in different ways; some are more common for certain applications than others. The most common implementations are as follows.

SNKR -- Sneakernet: In the CD exchange scenario, the information is exchanged in person or by mail, commonly referred to as the "sneakernet."

PPDCM -- Point-to-point DICOM: Images are typically exchanged between modalities or a PACS and pushed to a remote viewing station or to a teleradiology PACS server using the DICOM format and protocol. If one is using the public Internet, a virtual private network (VPN) is set up to guarantee confidentiality of the information to be exchanged. The DICOM protocol relies on the reliable delivery by the underlying TCP/IP communication layers. If the bandwidth of the connection is limited and/or the study sizes are large, standard DICOM compression is used such as JPEG or wavelet (aka JPEG2000).

GTWAY -- DICOM to edge server/gateway: If the connection to the Internet is unreliable or not available, one might need to use alternative communication channels such as the phone network or dedicated satellite links. In that case, an edge server or gateway is used that converts the DICOM protocol in a proprietary protocol, which in most cases uses a high compression ratio and very robust communication protocol. The gateway functions as a store-and-forward box, ensuring delivery. This edge server talks to a server or a destination that has the reverse gateway, i.e., it makes sure the images are received without any corruption and preferably then uses DICOM to pass them on. This solution is common for teleradiology applications in rural areas or disaster and military zones.

PPP -- Point-to-point proprietary: This is commonly used by workstations that access the PACS server of the same vendor. They use the radiology worklist provided by the PACS, and, if they use a public network, a VPN is needed to encrypt the information being exchanged.

WEB -- Web-based protocol: The Web-server clients typically use a secure HTTPS protocol to access the images. Some PACS vendors also use HTTPS for regular in-house image access, but this is uncommon.

EML -- Email: Emailing an image poses quite a few issues because the images are quite large even if they are compressed, and there is no context information. This assumes that one uses secure email to start with and that the receiver can recognize the .dcm file extensions that are created for that purpose. DICOM has addressed this, but the DICOM email has never taken off in the U.S., although it has been implemented in Germany and is somewhat common there.

XPHR -- Personal Health Record Exchange: This is an HL7 version 3 document exchange definition using the Clinical Document Architecture (CDA), which can exchange all relevant information between the PHR and EMR.

XDS-I -- Cross-Enterprise Document Sharing for Imaging: The IHE organization has defined a series of profiles, including how to exchange documents and images. The XDS-I profile uses a series of transactions that allow an image producer and consumer to exchange both registry and repository information with an HIE. The image exchange uses the Web version of the DICOM protocol, aka WADO, or Web Access to DICOM Objects. The XDS-I protocol is widely implemented by PACS vendors, especially those who claim to offer a VNA. However, the number of institutions that actually use this protocol, especially in the U.S., is still relatively sparse. Note that there are also different variants of this mechanism defined by IHE, i.e., the Cross Community Access for Imaging (XCA-I) and the Cross-Enterprise Document Reliable Interchange of Images (XDR-I). These don't use a registry but provide a direct query/retrieve and push mechanism for image exchange. These implementations are also still in their infancy.

RSTF -- Restful Services: A new version of the DICOM protocol is being defined that expands beyond the WADO protocol and has greater functionality. The "traditional" DICOM protocol that includes a negotiation step to set up the association between two devices and uses the DICOM-specific set of commands is not that suitable for accessing information over the Web. This new DICOM extension is still very much in its early phases, but it might become popular as the need for Web-based access, especially from embedded viewers in an EMR, becomes common.

INT -- Internet: Uploading images on a server via a proprietary protocol is typically used by social media, such as Facebook or other image-sharing services. The image would have to be converted to a Web-friendly image type such as JPEG or TIFF, which almost certainly affects the image quality. Therefore, one can typically only see gross anatomy; small findings are almost certainly not visible.

Some of the architectures and connections as described above are very mature, while others are very young. Teleradiology was implemented widely during the 1990s, but some of these methods such as cloud services, the XDS protocol, and Restful Services are still very much in their infancy.

There are many reasons for image exchange and several different architectures and implementations with different communication mechanisms. Both the industry and provider community are trying to figure out how and what to do, knowing that many of the solutions are still in the early phases of the technology hype cycle. Time will tell which method and protocol will prevail, but, as with any technology, there will always be other technologies pushing the curve. That makes this field so interesting and never boring.

Herman Oosterwijk is president of OTech, a healthcare imaging and IT company specializing in EMR, PACS, DICOM, and HL7 training.

With Facebook, you can track down buddies from high schools, ex-girlfriends/boyfriends (for better or worse), long lost cousins... and infectious diseases. Last year, public health officials in Minnesota capitalized on a tip from the social media platform to hunt down the source of a strep throat outbreak in a high school.

The tip came from a parent whose daughter was a member of the high school's female dance team. After noticing that an alarming number of the dancers had posted to the team's Facebook page with complaints of strep throat, or Group A streptococcus (GAS) pharyngitis, the observant guardian contacted the Minnesota Department of Health.

The health officials realized that posts to the Facebook page began to appear 24-48 hours after the team had thrown a banquet and about three days after a potluck with some male classmates.

Although strep throat is normally passed via people coughing up infected respiratory droplets, food contamination does occur in rare cases. This route was more common before modern refrigeration and the advent of pasteurization, especially through the consumption of raw milk.

The investigators started with classic detective work: 100 telephone interviews and nasal swabs from the attendees, associated family members, and male classmates. Leftover food was bagged, and all of the biological specimens were transported to the state's public health laboratory in St Paul.

All of the boys who attended the potluck were negative for strep, so this event was eliminated.

Individual leftover items from the banquet that were tested by 'DNA typing,' a form of genetic analysis that can decipher bacterial heritage. The health team found that only a pot of pasta contained GAS bacteria that matched the cultures collected from the dancers.

A couple of false leads — people who had GAS but did not attend the banquet — could have thrown the investigators, but DNA typing allowed them to precisely track the gene fingerprints of the bacteria in the pasta to the infections in the dancers.

Another set of interviews revealed that the parent who had made the pasta, along with their child, had caught the same variant of GAS over two weeks before the banquet. Furthermore one girl who hadn't attended the banquet, but eaten the leftover pasta, came down with this strain of strep. In other words, the food culprit was caught.

"We suspect cooked food was contaminated by respiratory droplets from a person who carried the strep bacteria in the throat when the food was cooling or reheating," said lead investigator and epidemic specialist Dr. Sarah Kemble of the Minnesota Department of Health. "The food probably was not kept hot or cold enough to stop bacterial growth."

To reduce the spread of foodborne illness, the authors recommended that large batches of prepared food be kept either hot or cold, as disease-causing bacteria love to roost at temperatures between 41°F to 140°F. People should also avoid cooking for groups if they have symptoms of a respiratory disease like strep and should always ask a doctor how long they should wait before prepping meals for others.

This isn't the first mysterious outbreak to be cracked by Facebook. Flu flare-ups have been identified using the popular social media tool.

Google Flu Trends and other websites like HealthMap have tried to harness the power of people conducting influenza-related searches when they are sick, but some have questioned whether these tactics are truly representative of an afflicted population, given not everyone is online. In addition flaws appeared in Google's system during America's severe bout of seasonal influenza this past spring, with search engine app dramatically overestimating the prevalence of the disease.

Odds are these computer bugs will be worked out by intrepid software programmers, and disease surveillance, like so many aspects of public life, will be added to the list of items that social media has revolutionized.

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